WM0100538_Monitoring Well Construction Application_20230313

FOR OFFICE USE ONLY

PERMIT NO. ISSUED DATE
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY

In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.

1. Date: 03/13/2023

2. County: Jackson

3. What type of well are you applying for? (monitoring or recovery): Monitoring

4. Applicant: NCDEQ Telephone: [phone]

Applicant’s Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699

Applicant’s Email Address (if available): [e-mail]

5. Contact Person (if different than Applicant): Greg Hans Telephone: [phone]

Contact Person’s Mailing Address: 3525 Whitehall Park Drive, Suite 150, Charlotte, NC 28273

Contact Person’s Email Address (if available): [e-mail]

6. Property Owner (if different than Applicant): Kathy Watkins Telephone: [phone]

Property Owner’s Mailing Address: PO Box 313, Webster, NC 28788

Property Owner’s Email Address (if available): N/A

7. Property Physical Address (Including PIN Number) 1674 East Main Street PIN 7641-70-5711
City Sylva County Jackson Zip Code 28779

8. Reason for Well(s): Assessment
(ex: non-discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)

9. Type of facility or site for which the well(s) is(are) needed: USTs
(ex: non-discharge facility, waste disposal site, landfill, UST, etc.)

10. Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).

No known water quality permits. UST Incident No.: 5325

11. Type of contaminants being monitored or recovered: organics / metals
(ex: organics, nutrients, heavy metals, etc.)

12. Are there any existing wells associated with the proposed well(s)? If yes, how many? No known

Existing Monitoring or Recovery Well Construction Permit No(s).:

13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): To be installed within Source Area and
Upgradient

14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes

If yes, give distance(s): Approximately 150 feet to the west-northwest

15. Well Contractor: Carolina Soil Investigation Certification No.: Corey Speece #2904 / Daniel
Summers #2579

Well Contractor Address: 132 Gurney Road, Olin, NC 28660

PROPOSED WELL CONSTRUCTION INFORMATION

1. As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following:

a. Borehole and well diameter e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
c. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of wells to be constructed in unconsolidated
material: 2

3. Number of wells to be constructed in bedrock: 0

4. Total Number of wells to be constructed: 2
(add answers from 2 and 3)
5. How will the well(s) be secured? 2 x 2 pad, well
covers, locking j-plug

6. Estimated beginning construction date: Week of
3/27/2023

7. Estimated construction completion date: Week of
3/27/2023

ADDITIONAL INFORMATION

1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:

a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
c. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.10B(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.

SIGNATURES

The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Environmental Division Manager
Signature of Applicant or *Agent Title of Applicant or *Agent

Greg Hans * If signing as Agent, attach authorization agreement stating
Printed name of Applicant or *Agent that you have the authority to act as the Agent.

If the property is owned by someone other than the Applicant, the property owner hereby consents to allow the Applicant to construct
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.

(See attached Access Agreement with NCDEQ State Trust Fund)
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)

DIRECTIONS

Please send the completed application to the appropriate Division of Water Resources’ Regional Office:

Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]

Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]

Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]

Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]

Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]

Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]

Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR (6/11)
TYPICAL 
FLUSH­MOUNT GROUNDWATER MONITORING WELL 
CONSTRUCTION DIAGRAM 
BOLTED MANHOLE COVER 
CONCRETE PAD 
MANHOLE SLEEVE 
LOCKING WELL CAP 
2” SCHEDULE 40 PVC PIPE 
BENTONITE GROUT 
BENTONITE SEAL 
TYPE _________ 
SAND PACK 
GRAIN SIZE _________ 
2” SLOTTED SCHEDULE 
40 PVC SCREEN 
BOTTOM CAP 
BOTTOM OF BORING 
ANNULUS 
(SPACING DEPENDS 
ON WELL DEPTH) 
2 FEET 
2 FEET 
10 FEET 
6” 
6” 
1”­2” 
2”­3” 
2”­3” 
(TOP OF MANHOLE) 
(TOP OF CASING) 
ENVIRONMENTAL PROTECTION 
HAZARDOUS SITES RESPONSE PROGRAM

Sharon Ghiold
DWM UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646

Dear Ms. Ghiold:

RE: Site Access Agreement
Former Ray’s Grocery
1674 E. Main Street
Sylva, Jackson County, North Carolina (ARO)
STF Incident 5325
Risk/Rank: High H145D

I am/We are the owner(s) of a parcel of property, located at or near the incident in question,
and hereby permit the Department of Environmental Quality (Department) or its contractor to enter
upon said property for the purpose of conducting an investigation of the groundwaters under the
authority of G.S. 143-215.3(a)2.

I am/We are granting permission with the understanding that:

1. The investigation shall be conducted by the UST Section of the Department’s Division of Waste
Management or its contractor.

2. The costs of construction and maintenance of the site and access shall be borne by the
Department or its contractor. The Department or its contractor shall protect and prevent damage
to the surrounding lands.

3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the
shortest feasible route to the nearest public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.

4. Any claims which may arise against the Department or its contractor shall be governed by
Article 31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.

5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1.

6. The activities to be carried out by the Department or its contractor are for the primary benefit
of the Department and of the State of North Carolina. Any benefits accruing to the owner are
incidental. The Department or its contractor is not and shall not be construed to be an agent,
employee, or contractor of the land owner.